Provider Demographics
NPI:1407215502
Name:FOREVER YOUNG TWO,LLC
Entity Type:Organization
Organization Name:FOREVER YOUNG TWO,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:MARGUERITE
Authorized Official - Last Name:BRINKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:763-272-1500
Mailing Address - Street 1:9766 FALLON AVE NE STE 102
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-4589
Mailing Address - Country:US
Mailing Address - Phone:763-272-1500
Mailing Address - Fax:763-272-1503
Practice Address - Street 1:9766 FALLON AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-4589
Practice Address - Country:US
Practice Address - Phone:763-272-1500
Practice Address - Fax:763-272-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0382194363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty